Evaluating the Effect of Nurse-Led Stroke Transitional Care in Tanzania

Evaluating the Clinical Effectiveness and Implementation Outcomes of Nurse-Led Stroke Transitional Care Model in Tanzania

The goal of this observational study is to assess the effects of nurse-led stroke transitional care in stroke survivors, caregivers and healthcare providers who participate in nurse-led stroke transitional care program to improve discharge preparedness, disease self-management and quality of life among stroke survivors. The main question it aims to answer is: does nurse-led stroke transitional care program improve discharge preparedness, disease self-management and quality of life among stroke survivors? Participants are currently participating in nurse-led stroke transitional care program as part of their medical care. Stroke survivors and their caregivers will be followed for six months period to assess their transitional care quality and clinical outcome measures.

Study Overview

• Status: Recruiting
• Conditions: Stroke Acute; Stroke (CVA) or Transient Ischemic Attack
• Intervention / Treatment: Behavioral: Nurse-led stroke transitional care program

• Study Type: Observational
• Enrollment (Estimated): 130

Contacts and Locations

• Study Contact: Name: Nyagwaswa Michael, Masters; Phone Number: +255685005923; Email: nyagwaswamichael04@gmail.com

Study Locations

• Tanzania
  • Dar es Salaam, Tanzania, 65001
    • Recruiting
    • Muhimbili University of Health and Allied Sciences
    • Contact: Nyagwaswa Michael, Masters; Phone Number: +255685005923; Email: nyagwaswamichael04@gmail.com
    • Contact: Lilian Mselle, PhD; Phone Number: +255717565610; Email: nakutz03@gmail.com
    • Principal Investigator: Nyagwaswa Michael, masters

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

• Sampling Method: Non-Probability Sample

Study Population

The study will include nurses, doctors, stroke survivors and caregivers who are directly involved in hospital-to-home transition.

Description

Inclusion criteria

• Clinical nurses and physicians with six months of working experience in stroke care
• Clinical nurses and physicians with a minimum of diploma in their professions.
• Stroke survivors with 18 years old and above
• Stroke survivors admitted in the stroke units
• Stroke survivors with primary diagnosis of stroke confirmed by brain CT/MRI
• Stroke survivors who undergo usual discharge process
• Stroke survivors who live with their family caregivers
• Stroke survivors who have mobile phones
• Stroke survivors who can read and write
• Stroke survivors who are able to communicate
• Stroke survivors with National Institutes of Health Stroke Scale (NIHSS) < 6
• Stroke survivors with Modified Barthel Index (MBI) > 9
• Stroke survivors with Modified Rankin Scale (mRS) < 5
• Stroke survivors with Montreal Cognitive Assessment Test (MoCA) > 14
• Stroke survivors who are expected to stay in the ward for 3-5 days,
• Stroke survivors who are expected to survive for 3 months
• Family caregivers with mobile phones
• Family caregivers who can read and write
• Family caregivers who are able to communicate
• Family caregivers who live with the patient after stroke

Exclusion criteria

• Healthcare providers who will be on leave during the study period.
• Stroke survivors with previous stroke who are not admitted in stroke units
• Stroke survivors who are discharged against medical advice
• Stroke survivors who have end-stage organ failure
• Stroke survivors who have family caregivers
• Stroke survivors who can't read/write
• Stroke survivors who have no mobile phones.
• Family caregivers without mobile phone that is accessible

Study Plan

How is the study designed?

Number of groups / cohorts

1

Cohorts and Interventions

Group / Cohort

Intervention / Treatment

Historical control group; Stroke survivors and their caregivers received usual care

Behavioral: Nurse-led stroke transitional care program; Participants in intervention group will receive usual care plus nurse-led stroke transitional care. Two nurse champions will conduct the face-to-face sessions while other two nurse researchers will conduct the telephone call sessions between August and December, 2025. During hospitalization, the two nurse champions will conduct five face-to-face sessions (2 individual sessions at admission; and at discharge), and three group sessions with 2-4 dyads of patients and caregivers. After hospitalization, two nurse researchers will conduct seven follow-up sessions for three months via phone calls at day 3, week 1, week 3, week 5, week 7, week 9, and week 11. The face-to-face sessions and phone call sessions will take 40-60 minutes and 20-30 minutes respectively

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Self-efficacy among stroke survivors	Ability to take control and perform recommended health behaviors and discharge instructions. Self-efficacy will be measured by the Stroke Self-Efficacy Questionnaire (a=0.9) developed by Jones and colleagues. This will be measured by a scale as total scores and mean scores. High total and mean scores indicate better ability to follow and adhere to healthy lifestyles after stroke	6 months after discharge
Quality of life among stroke survivors	Quality of life that will be measured by the Stroke Specific Quality of Life (SSQoL) with (a=0.85). This will be measured by a scale as total scores and mean scores. High total and mean scores indicate better quality of life as evidenced by ability to perform self-care activities, improved cognitive function, mobility, and engaging in social activities	6 months after discharge
Discharge preparedness among survivors	Discharge preparedness that will be measured by the Short Forms of the Readiness for Hospital Discharge Scale (RHDS) developed by Weiss. This will be measured by a scale as total scores and mean scores. High total and mean scores indicate readiness for hospital-to-home discharge among stroke survivors.	within 1 month after discharge
Discharge preparedness among health care providers	Discharge preparedness that will be measured by the Short Forms of the Readiness for Hospital Discharge Scale (RHDS) developed by Weiss. This will be measured by a scale as total scores and mean scores. High total and mean scores indicate agreement on readiness for hospital-to-home discharge among nurses and doctors.	within 1 month after discharge
Resilience among caregivers	Resilience will be measured by the 10-items Connor-Davidson Resilience Scale (CD-RISC) validated by Laura with a=0.85). This will be measured by a scale as total scores and mean scores. High total and mean scores indicate better ability and readiness to take care giving responsibilities.	6 months after discharge
Quality of transition care among survivors and caregivers	Quality of TC will be measured by the Care Transitions Measure (CTM) Tool developed by Eric Coleman. This will be measured by a scale as total scores and mean scores. High total and mean scores indicate better perceived quality of transition care.	within 1 month after discharge
Caregiver self-efficacy	Caregiver self-efficacy will be measured by the 10-items Family Caregiver Activation Tool (FCAT) developed by Coleman with a=0.6. This will be measured by a scale as total scores and mean scores. High total and mean scores indicate better ability to assist the stroke survivors to follow and adhere to healthy lifestyles and clinic appointment after stroke	6 months after discharge

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Depression and anxiety among survivors and caregivers	Depression and anxiety that will be measured by the locally validated 10-items Kessler Psychological Distress Scale with a=0.85. This will be measured by a scale as total scores and mean scores. High total and mean scores indicate poor mental health status after discharge.	6 months after discharge
Care satisfaction among survivors and caregivers	Satisfaction of hospital care will be measured by a questionnaire developed specific for this study. It will be measured as total scores and mean scores. High total and mean scores indicate good satisfaction with transitional care.	within 1 month after discharge
Mortality among survivors	This will be counted as a death event after discharge.	6 months after discharge
readmission among survivors	This will be measured as number of times the patient is readmitted at the hospital after discharge. High frequency will indicate many readmissions.	6 months after discharge
length of hospital stay among survivors	This will be measured as number of days spent in the hospital before discharge. This will be calculated as number of days spent at the hospital from admission to discharge. High number above 5 indicates long hospital stay.	Day 1 after discharge

Collaborators and Investigators

• Sponsor: Shandong University

Study record dates

Study Major Dates

• Study Start (Actual): August 1, 2025
• Primary Completion (Estimated): March 25, 2026
• Study Completion (Estimated): March 30, 2026

Study Registration Dates

• First Submitted: November 19, 2025
• First Submitted That Met QC Criteria: December 21, 2025
• First Posted (Actual): January 6, 2026

Study Record Updates

• Last Update Posted (Actual): January 6, 2026
• Last Update Submitted That Met QC Criteria: December 21, 2025
• Last Verified: December 1, 2025

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Cerebrovascular Disorders; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Vascular Diseases; Cardiovascular Diseases; Brain Ischemia; Stroke; Ischemic Attack, Transient
• Other Study ID Numbers: Shandong@2025; 72274110 (Other Grant/Funding Number: National Natural Science Foundation of China)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED
• IPD Plan Description: I will consider sharing it upon finishing enrollment of participants

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No